In-network and Out-of-network Pharmacy Costs
When you fill your prescription at a participating pharmacy, you will simply need to present your WellCare ID card. You will be responsible for any necessary out of pocket expense according to your Part D benefit.
WellCare has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/copayments/coinsurance may change on January 1 of each year.
If an in-network pharmacy is not available, you may need to use an out-of-network pharmacy to fill your prescriptions. An out-of-network pharmacy is a retail, long-term care, home infusion, or ITU pharmacy that is not in your plan’s network.
As a rule, prescription drugs filled at out-of-network pharmacies are only covered by your plan if you are unable to use a network pharmacy for any of these reasons:
- The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
- There are no participating network pharmacies when you travel outside of your service area
- The covered drug is prescribed for a medical emergency or urgent care and you are unable to fill your prescription immediately at a network pharmacy because there are no 24-hour network pharmacies within a reasonable driving distance
- The covered drug is out of stock at any network pharmacy in your area
- The covered drug (incl. high-cost and/or special drugs) cannot be obtained through CVS Caremark Mail Service Pharmacy or Exactus Specialty pharmacy due to the medication being out-of-stock or any other reasons
- You are administered a vaccine covered by your plan in a physician’s office
Please note that even if we pay for covered prescription drugs filled at an out-of-network pharmacy, you may still pay more than you would have paid if you had filled your prescriptions at an in-network pharmacy.
To receive reimbursement for our portion of your cost, you will have to submit a Direct Member Reimbursement Form. Mail the completed Direct Member Reimbursement form along with a prescription label or pharmacy printout and a cash register receipt for your covered prescription drug to:
WellCare Reimbursement Department
PO Box 31577
Tampa, FL 33631-3577
We will review the Direct Member Reimbursement Request form and make an initial out-of-network coverage determination. Your request will be processed according to your benefit coverage and you will be notified of the outcome. If our Direct Member Reimbursement policy requirements are met, you will be reimbursed at the “any willing provider in-network contracted rate” instead of the cash price minus any applicable co-pays. That means that you will pay the copay/co-insurance you would be responsible for under your plan plus the difference between the cash price and the plan allowance if the cash price is higher than the contracted rate.